When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you’re protected from surprise billing and balance billing.
Healthcare costs you’re responsible for paying
When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. These are called cost-sharing expenses. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network (out-of-network providers).
What is “balance billing”?
Out-of-network providers and facilities haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
Surprise billing is an unexpected balance bill. This can happen when you can’t control who is involved in your care — like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This protection includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers who work there may be out-of-network. In these cases, the most these providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. If your provider asks you to sign a waiver giving up your balance billing rights, you don’t have to sign the waiver. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
You’re only responsible for paying your share of the cost (like copayments, coinsurance and deductibles) that you would pay if the provider or facility was in-network. Your health plan will negotiate directly with out-of-network providers and facilities and pay any balance beyond your in-network, cost-sharing expenses.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance, which is called prior authorization.
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (your cost-sharing amount) on what the plan would pay an in network provider or facility and show that amount in your Explanation of Benefits statement.
- Count any amount you pay for emergency services or out-of-network services provided at in-network facilities toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the No Surprises Helpdesk operated by the U.S. Department of Health and Human Services in coordination with the Department of Labor: 1-800-985-3059.
Visit www.cms.gov/nosurprises for more information about your rights under federal law.